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Applications Will Be Processed When Submitted Properly Complet a e sure ioa�gn ne►appnc gyp <br /> FOR OFFICE USE: r i APPLICATION 1400 S 1982 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PiJ &WELL - <br /> f ENVIRONMENTAL HEALTH PER JGt-���.,�N LOCAL <br /> FIr <br /> $ DISTRICT <br /> IN TRIPLICATE) - � �p <br /> WATER QUALITY <br /> rht' I <br /> TI ri 1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein describ s application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> a ne City/Town Lodi ._Ca. 95260 <br /> Exact Site Address2 =- t <br /> fPhone _ 6g--9 0 �' 4 <br /> Owner's Name I <br /> AddressCityQ <br /> .Contractor's Name rWp <br /> _ License#_392542 Business Phone 334-9130 <br /> Contractor's Address Emergency Phone _ 30-A982 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW'WELL® DEEPEN 11REC0NDIT10N�[ DiESp <br /> TR©ValONa❑ �. <br /> € WELL CHLORINATION 1:1 WELL ABANDONMENT ❑ OTHER [I PUMP INSTALLATION ❑ PUMP REPAIR❑ v ; <br /> REPLACEMENT❑ - <br /> DISTANCE TO NEAREST: Septic Tank3_5 —Sewer'Lines — Pit Privy <br /> � - Sewage Disposal Field Cesspool75eepage Pit IZ Other' <br /> Property Line 100, Private Domestic Well 80 ft Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1 <br /> 11 INDUSTRIAL CABLE TOOL Dia. of Well Excava55 tion �O tU� 50 � It <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE �`�•=��;,l : _,;,� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 10 F7-a . <br /> 11 IRRIGATION ❑ GRAVEL PACK Depth of-Grout Seal 5Q f t • - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY '. Type of Grouf - g Sk • <br /> 13 DISPOSAL ❑ OTHER Other Informatiori`� T <br /> 11GEOPHYSICAL . Surface Seal'lrtstallecl By: ®VHSw ay <br /> PUMP INSTAL`ATION: Contractor , <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ❑ State Work Done <br /> PUMPfREPAIR: <br /> � ELL: Well Diameter Approximate Depth <br /> DESTRUCTION OF W <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County v <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this per <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhic f his ,. <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> I w'I rout 1 pect' rlor to grouting and a final inspection. <br /> Signed X , <br /> Title: Can'traetor Date: Nov. 4. 1982 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I_- <br /> I Applicatiorl'Accepted Date i r T <br /> Additional Comments: �} <br /> Phase11 rout Inspec ion Phase 111 Final inspection to fl <br /> Inspection By to <br /> — C/'�� Inspection By Date <br /> � `° <br /> .4— 3-e 3 <br /> Fee I5 DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Jan ry 31 ❑ July 1 &Received 8y July 31 a� / <br /> REMIT L <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT 1 <br /> FEE.. r - <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY - <br /> 'OTHER <br /> OTHER. ` <br /> } S CA <br /> �r <br /> Issuance Date Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. t <br /> APPLICANTS RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .` 1601'E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - - <br />